Matthew R. Summers, M.D., describes the use of intravascular lithotripsy for management of calcified plaque in multi vessel diseased coronary arteries.
So the first case I wanted to show is a 72 year old female that came in in 2018 with an anterior my She ended up having a PC to approximate lady subsequent to that. She had an injection fraction at 25%. That improved after revascularization. GMT to about 40 to 45 For us, declined throughout 2020-20%. Respect, demonstrated a fixed anterior wall defect. There was no cath or viability performed, which she ended up having a primary drenched in place. She had atrial fibrillation and CKd COPD and diabetes. So she came into an outside hospital with accelerated engine on a heart failure. Positive proponents. Her E K. G, uh didn't show any systemic STT changes, but speaking to potential viability, she had very few Q waves, just very small intercept accuse. And our Echo showed any effort that was now declined 15-20%. They're standing really only at that a pickle septum. Um, we weren't able to perform viability testing in her because of the primary prevention, which was not very compatible, but the constellation of findings on her E. K. G. And Echo supported the idea of viability throughout the interior wall. Her catheterization at the outside demonstrated Peyton, right coronary artery. You can see on the right, she had an undersized stent in the hostility protruding and have left main with a severely calcified osteopath proximal circumstances done at the outside hospital. You can appreciate the complexity of that left me and particularly in the context of having an undersized protruding stand adjacent to pretty significant, sir, complex calcification. So outside operator put FFR wires down both branches and show that they were significant. Also supporting the concept of viability. L. G. D. P. Was elevated as well so supporting the presentation of be compensated heart failure. This is what we did in the cath lab. So we put in an appellate cp given a reduced ejection fraction, the left main complex lesion that we were treating. We did that single access from the right side which is how we're doing most of our compelling cases. Nowadays we just have one single access and we puncture the impeller sheath put in our catheter. So this is all done through one hole and closed with the manta at the end seven French Review Guide. We had a she in blue down the lady in a pro water down the circum flex. And this is what we see in true coronary. So when the lady in the upper left you see a 2.5 millimeter stent not even opposed to the blood vessel wall. So very very undersized. There is an arc of calcium around that lady. But predominantly it's undersized. And then in the lower left you see the circum flex which is near circumferential calcification. So this is where we use is one of the first cases we use shockwave in traditionally I think we would use laser a threat to me in that instant restenosis but that really affects calcium to a minor extent relative to the other a threat to me devices. We have to choose between maybe a less effective way to deal with the calcium and in order to break up some of the scarring and expand the stent versus using a rotational mechanism like orbital for rhoda. Uh an extent that's only a year and a half of which comes with a variety of risks including preparation and mobilisation of metal downstream and so shocking. It was actually very, very useful in this case. We could wire both branches deploy shockwave across each branch is at 40 pulses in the lady and the under expanded stent but also into the Osteo Sir complex and impact that calcium. We proceeded with the DK crush of the left main used a 332 synergy slightly retreating in the left main crushed this and then put a 438 Pegatron from the left main of the lead. Were able to take that to five stent and dilated in the L 82 35. after shockwave And we're able to pop in the left main with 5.5. This is the idea that completions the lady on the left so that under expanded sent is now expanded and that's the Quran on the right demonstrating a good criminal, incomplete expansion of the left main in the second case before I pass it off the wall. This is stratification. Left main, an 82 year old male that had COPD and liver disease. He came in as well with the company compensated heart felt that was new and stemming His EF was newly depressed at 15%. He sustained BT while he was awaiting for transfer here for further treatment. You can see a very complex left main trip vacation typically when we're dealing with left main trip vacations one of the three branches um who would basically provisionally treat and that's usually the ramos but this is a sizable ramos has approximately disease so likely needs to be treated with standing up front. The other complex part here is that that sir complex takes an abrupt acute angle backwards after the calcification. And it's obviously something we wouldn't want to lose in the pc. So all three branches need to be treated again. This is in Pella from the right but single access um the lady wired Luther she in blue the ramos with a run through but I could not wire the Sir complex with that angle. Almost a video there's integrate flow of course, but that calcification that was very very difficult to get wires enough to penetrate through. Used something called hairpin wire and angled micro catheters tried to wire through this side brand side port of a balloon micro catheter all unsuccessfully. More importantly when we were when I was doing this case uh circumstance flex went down when we were trying to wire it. I did was take a little trip see from the left main to the lady and then in the left main to the ramos and attempt to deal with that calcium. Hopefully open up the side branch. Make change the geography enough to allow for wiring. And that's what occurred. So after little trips into the room adjacent to the vessel opened back up and then with wires that I was trying to use before they would wire. That's so complex. So then the techniques employed to the trip vacation stenting to do true try applications sensing enough. Provisional with the third grant involves doing a coat which is two stents, one from the left hand and led and the other inside of it in the left lane into the complex and doing what's called a T. And protrusion center that ramos and doing a basically a triple kiss which is in the upper, upper right. That's your final result there.
